Physicians may be more likely to accept gifts from industry if they feel a sense of entitlement because of the sacrifices they've made, researchers discovered.

Action Points

Explain to interested patients that physicians may be more likely to accept gifts from industry if they feel a sense of entitlement because of the sacrifices they've made.

Note that the study suggests that financial self-interest isn't the only reason such gifts are accepted and that even well-intentioned physicians may justify acceptance based on perceived hardships.

Physicians may be more likely to accept gifts from industry if they feel a sense of entitlement because of the sacrifices they've made, researchers discovered.

A reminder of the things given up to get a medical education more than doubled the number of residents who called industry-sponsored gifts acceptable (47.5% versus 21.7% of controls, P=0.001), according to Sunita Sah, MBChB, MBA, and George Loewenstein, PhD, both of Carnegie Mellon University in Pittsburgh.

In the randomized trial using different survey formats, adding a statement rationalizing the gifts before asking about acceptability boosted the likelihood of acceptance even further, they reported in the Sept. 15 issue of the Journal of the American Medical Association.

Financial self-interest isn't the only reason such gifts are accepted -- even well-intentioned physicians may justify acceptance based on perceived hardships, Sah and Loewenstein concluded.

These "troubling" results suggest a way that physicians can be manipulated for marketing purposes, noted Stephen G. Pauker, MD, and John B. Wong, MD, both of Tufts Medical Center in Boston.

They lamented in an accompanying editorial that "current medical education generally does not teach students how to manage such conflicts, whether regarding ethical principles about personal economic behavior, the ethics of patient care (e.g., beneficence versus autonomy), or multifaceted loyalties (e.g., to patients, institutions, society, or third-party payers)."

Sah and Loewenstein tested for a causal connection between rationalizations and acceptance of industry gifts among pediatrics residents at one hospital and family medicine residents in programs around the country.

The 301 residents who responded were randomized to one of three online surveys all of which focused on values, quality of life, and expectations without mentioning conflicts of interest.

One survey asked physicians about the sacrifices made to obtain their medical education, followed by questions about the acceptability of accepting gifts from industry, and then posed a "rationalization." The rationalization question asked respondents how much they agreed with the statement, "Some physicians believe that the stagnant salaries and rising debt levels prevalent in the medical profession justifies accepting gifts and other forms of compensation and incentives from the pharmaceutical industry."

This questionnaire was referred to as the "sacrifice reminders" survey.

The second survey asked the same questions about sacrifices and accepting gifts, but inserted the "rationalization" between the two sets of questions. It was dubbed the "suggested rationalization" survey, posing that question before the responses to the acceptability of receiving gifts was already locked in.

The third, control, survey asked about the acceptability of taking gifts before introducing either the reminder of sacrifices or the suggested rationalization.

The order appeared to make a difference -- physicians were nearly twice as likely to endorse the rationalization if it came immediately after the sacrifice question than if it came at the end of the survey (47.1% versus 30.0% in the control survey and 31.7% of those asked about sacrifices first, P=0.02).

Even though most residents disagreed with the suggested rationalization, exposure to it further boosted the perceived acceptability of receiving gifts to 60.3% in the suggested-rationalization group (odds ratio 1.45, P<0.001 versus sacrifice reminders group).

Notably, those who disagreed with the rationalization actually appeared most vulnerable to influence.

"This suggests that 'because you're worth it' primes, such as those provided by sacrifice reminders and suggested rationalizations, are especially effective for those who would, in their absence, be least likely to accept gifts," the researchers wrote in the paper, adding, "The justifications may not occur on a conscious level."

Physicians who felt they were working under poor conditions or felt poor were more likely to agree with the rationalization (P=0.02 and P=0.04, respectively).

The researchers cautioned that they couldn't determine the response rate among family medicine residents.

Moreover, survey participation was motivated by the chance to win money or a portable media player, so it is possible that the survey attracted physicians who were more attracted to gifts, the investigators noted.

The study was supported by Carnegie Mellon's internal departmental research funds.

The researchers reported having no conflicts of interest to disclose.

Wong reported receiving an honorarium for a book related to clinical decision reasoning. Pauker reported no disclosures.